Specialty
Spotlight

 




 


Anaesthesia


   

 




Epidural
Analgesia

     

  • Intact
    Proprioception and control of Labour Pain during
    Epidural Analgesia.



    Acta
    Anaesthesiol Scand 43:46-50, 1999

       

    Anesthesiologists
    are increasingly using a combination of a local
    anesthetic and an opioid administered into the
    epidural space for pain control in labor. 
    The combination allows the anesthesiologist
    to reduce the local anesthetic dose thereby reducing
    the risks of inadvertent spinal injection, postural
    hypertension, and lower extremity motor impairment
    to the point that such women may, with care, be
    allowed to move and ambulate during labor. 
    In this way, the superior systemic pain
    relief of the opioid during labor is coupled with
    superior pain relief during delivery offered by
    conduction anesthesia. 
    The disadvantages of opioid 
    administration are, principally, pruritis, a
    spontaneous complaint in 8% of the women reported
    here, and nausea, as well as an occasional episode
    of postpartum maternal respiratory depression that
    necessitates careful immediate postpartum
    surveillance.  Neither
    of the latter 2 complications were noted in this
    study.

       

  • Schorr
    SJ, Speights SE, Ross EL, et al [ Univ of Mississippi, Jackson]


    A Randomized Trial of Epidural Anesthesia to Improve External Cephalic Version Success


    Am J Obstet Gynecol 177 : 1133- 1137, 1997

     


    Purpose Several approaches have been tried to improve the success rate of external cephalic version in pregnancies with breech presentation. A recent retrospective study suggested that regional anesthesia improved the success of external cephalic version with no increase in fetal or maternal morbidity. This prospective study evaluated the use of epidural anesthesia for external cephalic version.

     


    Methods The randomized trial included 9 women at more than 37 weeks’ gestation with breech presentation who were scheduled for external cephalic version. One group of women received epidural anesthesia, and the other did not. Version was performed under ultrasound guidance, with up to 3 attempts made.

     


    Results The 2 groups were similar in terms of maternal age, parity, and weight; gestational age; estimated fetal weight; and station of the presenting part. External cephalic version was successful in 69% of women receiving epidural anesthesia compared with 32% of the control group.

      


    Editorial Comments In the past, some obstetricians have expressed concern that administration of analgesia/ anesthesia may allow an increased risk of excessive force during external cephalic version, which might result in an increased risk of adverse outcome. These obstetricians contend that the absence of analgesia/anesthesia requires the obstetrician to be gentle and avoid excessive force. In the present study, the authors demonstrated and 2-fold increase in the incidence of successful external cephalic version in the epidural analgesia group. The authors did not compare neonatal outcome in the 2 groups.,but they stated that there were no cases of fetal distress or abruptio placentae in either group. The authors performed real-time ultrasonography to monitor the fetal heart rate during the procedure, which likely enhances the safety of this procedure.

       

  • Bofill JA, Vincent RD, Ross EL, et al [Wright State Univ, Dayton, Ohio; Univ of Alabama at Birmingham; Univ Mississippi Med Ctr, Jackson]


    Nulliparous Active Labor, Epidural Analgesia, and Cesarean Delivery for Dystocia


    Am J Obstet Gynecol 177: 1465-1470, 1997

     


    Purpose Some studies have suggested that epidural analgesia increases the risk of dystocia-related cesarean delivery. Other studies have found no such effect. This randomized trial sought to determine the impact of epidural analgesia on the rate of cesarean delivery for dystocia among nulliparous women in active labor.

     


    Methods The study included 100 nulliparous women in active labor. The results shows cesarean delivery for dystocia occurred in 8% of the epidural group and 6% of the narcotic group. All labor times, including the duration of the first and second stages, were similar between groups. The rate of operative vaginal delivery was higher in the epidural group. The pain scores were similar at randomization, but significantly higher in the narcotic group at every hour thereafter. This randomized trial including a strict labor management protocol and criteria for the diagnosis of active labor does not find that epidural analgesia increases the risk of cesarean delivery. The study overcomes the shortcomings of previous studies of this question. It includes nulliparous women only; the findings do not apply to multiparous women or to women attempting vaginal birth after cesarean delivery.

     


    There is one more publication on the same subject by D.H. Chestnut, D.H. University of Alabama at Birmingham and he has reviewed the evidence of both sides of the issue whether epidural analgesia during labor increases the incidence of cesarean delivery and he says that there is no convincing evidence that giving epidural analgesia will ever increase the rate of cesarean delivery; the risk is more likely to be affected by maternal fetal factors and obstetric management. Pregnant women in labor can safely undergo epidural analgesia given by skilled aneasthesiologist. Denying these patients access to epidural analgesia will cause them avoidable pain without significantly lowering cesarean delivery rate. ` 

    One more publication on epidural analgesia and incidence of cesarean delivery for dystocia is by Fogel ST, Shyken JM et al. They conclude that the epidural analgesia is associated with but does not cause cesarean delivery for dystocia. Limiting epidural availability will not decrease cesarean delivery rate.

       

  • Gaiser RR, Cheek TG, Adams HK, et al [ Univ of Pennsylvania, Philadelphia]


    Epidural Lidocaine for Cesarean Delivery of the Distressed Fetus


    Int J Obstet Anesth 7: 27-31, 1998

     


    Objective Epidural anesthesia can be used for urgent cesarean delivery of a distressed fetus. Chloroprocaine is most commonly used in this situation; lidocaine with epinephrine and sodium bicarbonate also has a rapid onset of action. These 2 anesthetics were compared for epidural use in cesarean delivery of the distressed fetus.

     


    Results Both regimens produced adequate anesthesia; none of the patients required supplemental anesthetic. Time to achieve a T4 sensory level was 3.1 with chloroprocaine versus 4.4 min with lidocaine. Apgar scores and neurologic and adaptive capacity scores wee similar between groups. Maternal serum samples contained detectable lidocaine in 4 of the urgent case and all of the elective cases. Five newborns in the elective group had detectable serum lidocaine compared with none from the urgent group.

     


    Conclusion In women in labor with epidural catheters in place and a baseline epidural infusion to maintain a T10 sensory level, chloroprocaine has a faster onset than lidocaine. However, when chloroprocaine use is undesirable, lidocaine with sodium bicarbonate and epinephrine also provides a fast onset of labor analgesia. This study finds no evidence of significant ion trapping of lidocaine in distressed fetuses.

     


    When used to extend preexisting epidural analgesia for emergency cesarean section, the onset of anesthesia is approximately 2 minutes faster with 2-chloroprocaine than with lidocaine with epinephrine and
    bicarobonate.

       

  • R Burstal , F Wegener, C Hayes, et al


    Epidural Analgesia; Prospective Audit of 1062 Patients


    Anaesth Intensive Care 26 : 165-172, 1998

     


    The side effects and complications of epidural analgesia were prospectively determined.

     


    A survey of 1060 surgical patients aged 6 weeks to 92 years, who received at least one epidural analgestic infusion, was conducted over 2 years. Success or failure of analgesia, side effects and complications were recorded.

     


    Local anesthetic and an opioid mixture were used in 1131 infusions, and opioids along in 160 infusions. Infusions sites included 805 thoracic, 485 lumbar and 1 cervical. Duration of infusion averaged 2.7 days and ranged from 1 to 15 days. Catheter related complications requiring early removal included 139 dislodgements, 57 catheter site inflammations, 40 catheter leaks, 5 catheter site infections requiring antibiotics, 3 IV catheter migrations and 1 subarachnoid catheter migration. There were 347 major and 99 minor technique related complications. Patients receiving 0.125% bupivacaine and fentanyl had significantly more leg weakness and anesthesia failure than those receiving 0.25% bupivacaine and fentanyl : the latter had significantly more pruritus and respiratory depression and significantly more required naloxone. One third of the 14% anesthesia failures were converted to satisfactory blocks but the remaining had their catheters replaced or had another analgesia technique performed.

     


    Although epidural anesthesia can be used successfully and safely in most patients as many as 20% will not receive adequate analgesia. Accidental dislodgment of the catheter is a major cause of analgesia failure.

       

  • Abrahams
    M, Higgins P, Whyte P, et al (Rotunda Hosp., Dublin)

    Intact
    Proprioception and control of Labour Pain during
    Epidural Analgesia.

    Acta
    Anaesthesiol Scand 43:46-50, 1999

      

    Anesthesiologists
    are increasingly using a combination of a local
    anesthetic and an opioid administered into the
    epidural space for pain control in labor.
    The combination allows the anesthesiologist
    to reduce the local anesthetic dose thereby reducing
    the risks of inadvertent spinal injection, postural
    hypertension, and lower extremity motor impairment
    to the point that such women may, with care, be
    allowed to move and ambulate during labor. 
    In this way, the superior systemic pain
    relief of the opioid during labor is coupled with
    superior pain relief during delivery offered by
    conduction anesthesia.
    The disadvantages of opioid 
    administration are, principally, pruritis, a
    spontaneous complaint in 8% of the women reported
    here, and nausea, as well as an occasional episode
    of postpartum maternal respiratory depression that
    necessitates careful immediate postpartum
    surveillance.  Neither
    of the latter 2 complications were noted in this
    study.

     

    Currently,
    the anesthesia literature reflects an attempt to
    find an optimal dose of both agents to provide
    maximal analgesia with minimum side effects from
    either agent. In
    this study, the bupivacaine dose is reduced to 15
    mg, small enough so that inadvertent spinal
    introduction is not a hazard, plus 100
    mg
    of fentanyl.

      

    Careful
    neurologic examination confirmed that vibration
    sense and proprioception were maintained in the
    lower extremities and that the Romberg test of
    posterior spinal column function was normal in the
    women treated. Pain
    relief reported by study participants was excellent.
    By now, most obstetricians have encountered
    this approach to labor analgesia, which rests on a
    firm foundation of reported experience.

          




 

 

Specialty Spotlight

 

 
Anaesthesia
   

 

Epidural Analgesia
     

  • Intact Proprioception and control of Labour Pain during Epidural Analgesia.
    Acta Anaesthesiol Scand 43:46-50, 1999
       
    Anesthesiologists are increasingly using a combination of a local anesthetic and an opioid administered into the epidural space for pain control in labor.  The combination allows the anesthesiologist to reduce the local anesthetic dose thereby reducing the risks of inadvertent spinal injection, postural hypertension, and lower extremity motor impairment to the point that such women may, with care, be allowed to move and ambulate during labor.  In this way, the superior systemic pain relief of the opioid during labor is coupled with superior pain relief during delivery offered by conduction anesthesia.  The disadvantages of opioid  administration are, principally, pruritis, a spontaneous complaint in 8% of the women reported here, and nausea, as well as an occasional episode of postpartum maternal respiratory depression that necessitates careful immediate postpartum surveillance.  Neither of the latter 2 complications were noted in this study.
       

  • Schorr SJ, Speights SE, Ross EL, et al [ Univ of Mississippi, Jackson]
    A Randomized Trial of Epidural Anesthesia to Improve External Cephalic Version Success
    Am J Obstet Gynecol 177 : 1133- 1137, 1997
     
    Purpose Several approaches have been tried to improve the success rate of external cephalic version in pregnancies with breech presentation. A recent retrospective study suggested that regional anesthesia improved the success of external cephalic version with no increase in fetal or maternal morbidity. This prospective study evaluated the use of epidural anesthesia for external cephalic version.
     
    Methods The randomized trial included 9 women at more than 37 weeks’ gestation with breech presentation who were scheduled for external cephalic version. One group of women received epidural anesthesia, and the other did not. Version was performed under ultrasound guidance, with up to 3 attempts made.
     
    Results The 2 groups were similar in terms of maternal age, parity, and weight; gestational age; estimated fetal weight; and station of the presenting part. External cephalic version was successful in 69% of women receiving epidural anesthesia compared with 32% of the control group.
      
    Editorial Comments In the past, some obstetricians have expressed concern that administration of analgesia/ anesthesia may allow an increased risk of excessive force during external cephalic version, which might result in an increased risk of adverse outcome. These obstetricians contend that the absence of analgesia/anesthesia requires the obstetrician to be gentle and avoid excessive force. In the present study, the authors demonstrated and 2-fold increase in the incidence of successful external cephalic version in the epidural analgesia group. The authors did not compare neonatal outcome in the 2 groups.,but they stated that there were no cases of fetal distress or abruptio placentae in either group. The authors performed real-time ultrasonography to monitor the fetal heart rate during the procedure, which likely enhances the safety of this procedure.
       

  • Bofill JA, Vincent RD, Ross EL, et al [Wright State Univ, Dayton, Ohio; Univ of Alabama at Birmingham; Univ Mississippi Med Ctr, Jackson]
    Nulliparous Active Labor, Epidural Analgesia, and Cesarean Delivery for Dystocia
    Am J Obstet Gynecol 177: 1465-1470, 1997
     
    Purpose Some studies have suggested that epidural analgesia increases the risk of dystocia-related cesarean delivery. Other studies have found no such effect. This randomized trial sought to determine the impact of epidural analgesia on the rate of cesarean delivery for dystocia among nulliparous women in active labor.
     
    Methods The study included 100 nulliparous women in active labor. The results shows cesarean delivery for dystocia occurred in 8% of the epidural group and 6% of the narcotic group. All labor times, including the duration of the first and second stages, were similar between groups. The rate of operative vaginal delivery was higher in the epidural group. The pain scores were similar at randomization, but significantly higher in the narcotic group at every hour thereafter. This randomized trial including a strict labor management protocol and criteria for the diagnosis of active labor does not find that epidural analgesia increases the risk of cesarean delivery. The study overcomes the shortcomings of previous studies of this question. It includes nulliparous women only; the findings do not apply to multiparous women or to women attempting vaginal birth after cesarean delivery.
     
    There is one more publication on the same subject by D.H. Chestnut, D.H. University of Alabama at Birmingham and he has reviewed the evidence of both sides of the issue whether epidural analgesia during labor increases the incidence of cesarean delivery and he says that there is no convincing evidence that giving epidural analgesia will ever increase the rate of cesarean delivery; the risk is more likely to be affected by maternal fetal factors and obstetric management. Pregnant women in labor can safely undergo epidural analgesia given by skilled aneasthesiologist. Denying these patients access to epidural analgesia will cause them avoidable pain without significantly lowering cesarean delivery rate. ` 
    One more publication on epidural analgesia and incidence of cesarean delivery for dystocia is by Fogel ST, Shyken JM et al. They conclude that the epidural analgesia is associated with but does not cause cesarean delivery for dystocia. Limiting epidural availability will not decrease cesarean delivery rate.
       

  • Gaiser RR, Cheek TG, Adams HK, et al [ Univ of Pennsylvania, Philadelphia]
    Epidural Lidocaine for Cesarean Delivery of the Distressed Fetus
    Int J Obstet Anesth 7: 27-31, 1998
     
    Objective Epidural anesthesia can be used for urgent cesarean delivery of a distressed fetus. Chloroprocaine is most commonly used in this situation; lidocaine with epinephrine and sodium bicarbonate also has a rapid onset of action. These 2 anesthetics were compared for epidural use in cesarean delivery of the distressed fetus.
     
    Results Both regimens produced adequate anesthesia; none of the patients required supplemental anesthetic. Time to achieve a T4 sensory level was 3.1 with chloroprocaine versus 4.4 min with lidocaine. Apgar scores and neurologic and adaptive capacity scores wee similar between groups. Maternal serum samples contained detectable lidocaine in 4 of the urgent case and all of the elective cases. Five newborns in the elective group had detectable serum lidocaine compared with none from the urgent group.
     
    Conclusion In women in labor with epidural catheters in place and a baseline epidural infusion to maintain a T10 sensory level, chloroprocaine has a faster onset than lidocaine. However, when chloroprocaine use is undesirable, lidocaine with sodium bicarbonate and epinephrine also provides a fast onset of labor analgesia. This study finds no evidence of significant ion trapping of lidocaine in distressed fetuses.
     
    When used to extend preexisting epidural analgesia for emergency cesarean section, the onset of anesthesia is approximately 2 minutes faster with 2-chloroprocaine than with lidocaine with epinephrine and bicarobonate.
       

  • R Burstal , F Wegener, C Hayes, et al
    Epidural Analgesia; Prospective Audit of 1062 Patients
    Anaesth Intensive Care 26 : 165-172, 1998
     
    The side effects and complications of epidural analgesia were prospectively determined.
     
    A survey of 1060 surgical patients aged 6 weeks to 92 years, who received at least one epidural analgestic infusion, was conducted over 2 years. Success or failure of analgesia, side effects and complications were recorded.
     
    Local anesthetic and an opioid mixture were used in 1131 infusions, and opioids along in 160 infusions. Infusions sites included 805 thoracic, 485 lumbar and 1 cervical. Duration of infusion averaged 2.7 days and ranged from 1 to 15 days. Catheter related complications requiring early removal included 139 dislodgements, 57 catheter site inflammations, 40 catheter leaks, 5 catheter site infections requiring antibiotics, 3 IV catheter migrations and 1 subarachnoid catheter migration. There were 347 major and 99 minor technique related complications. Patients receiving 0.125% bupivacaine and fentanyl had significantly more leg weakness and anesthesia failure than those receiving 0.25% bupivacaine and fentanyl : the latter had significantly more pruritus and respiratory depression and significantly more required naloxone. One third of the 14% anesthesia failures were converted to satisfactory blocks but the remaining had their catheters replaced or had another analgesia technique performed.
     
    Although epidural anesthesia can be used successfully and safely in most patients as many as 20% will not receive adequate analgesia. Accidental dislodgment of the catheter is a major cause of analgesia failure.
       

  • Abrahams M, Higgins P, Whyte P, et al (Rotunda Hosp., Dublin)
    Intact Proprioception and control of Labour Pain during Epidural Analgesia.
    Acta Anaesthesiol Scand 43:46-50, 1999
      
    Anesthesiologists are increasingly using a combination of a local anesthetic and an opioid administered into the epidural space for pain control in labor. The combination allows the anesthesiologist to reduce the local anesthetic dose thereby reducing the risks of inadvertent spinal injection, postural hypertension, and lower extremity motor impairment to the point that such women may, with care, be allowed to move and ambulate during labor.  In this way, the superior systemic pain relief of the opioid during labor is coupled with superior pain relief during delivery offered by conduction anesthesia. The disadvantages of opioid  administration are, principally, pruritis, a spontaneous complaint in 8% of the women reported here, and nausea, as well as an occasional episode of postpartum maternal respiratory depression that necessitates careful immediate postpartum surveillance.  Neither of the latter 2 complications were noted in this study.
     
    Currently, the anesthesia literature reflects an attempt to find an optimal dose of both agents to provide maximal analgesia with minimum side effects from either agent. In this study, the bupivacaine dose is reduced to 15 mg, small enough so that inadvertent spinal introduction is not a hazard, plus 100 mg of fentanyl.
      
    Careful neurologic examination confirmed that vibration sense and proprioception were maintained in the lower extremities and that the Romberg test of posterior spinal column function was normal in the women treated. Pain relief reported by study participants was excellent. By now, most obstetricians have encountered this approach to labor analgesia, which rests on a firm foundation of reported experience.
          

 

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